Bedside Shift Reporting: Improving Nurse Handoff Communication

Introduction

Nurse handoff communication during shift change is one of the most frequent yet critical nursing duties, providing the basis for delivering safe, reliable care (Eggins & Slade, 2015). Research reveals that ineffective nurse communication at the time of patient handoff is a primary cause of sentinel events (Drach-Zahavy & Hadid, 2015; Eggins & Slade, 2015). The WHO (World Health Organization), AHRQ (Agency for Healthcare Research and Quality), and other health organizations recognize the significance of addressing risks to patient safety linked to ineffective handoff communication. Together with the National Patient Safety Goals (NPSG) for improving the efficacy of communication among caregivers, these organizations have put forward recommendations for improving upon this problem (Drach-Zahavy & Hadid, 2015).

North Caroky Hospital is a small 35-bed community hospital employing twenty 12-hour night shift nursing personnel. The hospital nurses' failure to provide quality Bedside Shift Reporting (BSR) can, to a great extent, adversely influence patient outcomes. Ineffective communication can cause treatment delays or the administration of incorrect treatment, needless preventable expenses, unplanned extension of hospitalization duration, lower personnel and patient satisfaction rates, and, ultimately, harm to the patient (Drach-Zahavy & Hadid, 2015). This paper discusses a focused, evidence-based project that attempts to improve BSR quality among those twenty 12-hour night shift nursing staff in the hospital's medical-surgical division by implementing a standardized instrument for BSR, targeted at improving the quality of communication among nursing personnel and avoiding clinical errors.

Clinical Leadership Theme and Organizational Problem

Some of the themes for improving clinical leadership identified in the course of this project are patient safety, employee and patient satisfaction, and employee communication. A broad theme statement for the project may be stated as follows: the hospital endeavors to enhance the quality of handoff communication during shift changes in the medical-surgical division by implementing a standardized instrument for BSR. This instrument addresses five major nursing behaviors: introduction, preparation, exchange of information, safety examination, and patient participation. The process commences with appropriate preparation of incoming nurses and culminates in steady, high-quality BSR delivery without miscommunication that could harm patients. The project is anticipated to: (1) enhance patient safety; (2) increase employee and patient satisfaction; (3) improve nurse–patient communication; and (4) prevent needless hospital expenses. These efforts are imperative given the identified needs: improving patient safety through better communication, increasing employee and patient satisfaction, and averting communication errors during shift change.

This BSR project covers the CNL (Clinical Nurse Leader) curricular component of managing the care environment. It aims to bring about improvements in patient safety and satisfaction and to reinforce collaboration by improving the communication process at the time of shift change in the orthopedic division. CNL roles responding to this project are Team Manager, Information Manager, and System Analyst.

The issue identified at the hospital is inadequate communication among nursing care workers while verbally reporting to peers at the time of shift change. For improving nurse-to-nurse and nurse-to-patient communication, thorough bedside reporting during shift change is necessary. Such a move will improve patient satisfaction and outcomes and communication among nursing staff, while promoting patient participation in their respective care plans.

Patient handoff may be defined as the transfer of patient care between two care providers. During this transition, patients are at maximum risk of suffering communication-related errors. Observations of the targeted clinical microsystem process revealed that night shift nursing staff did not consistently provide quality BSR; in fact, some nurses did not perform BSR at all. Instead, shift reporting was undertaken away from the patient bedside, in hospital hallways or at nursing stations. This project recognizes the likely obstacles revealed via a nursing survey administered prior to implementation, including nurse mindsets, views, and beliefs pertaining to performing BSR. Nursing workers believe quality BSR performance is contingent on time availability, linguistic obstacles, patient conformity, employee outlooks or resistance, and concerns about Health Insurance Portability and Accountability Act (HIPAA) violations (Boshart, 2016; Ford & Heyman, 2017).

Between-shift nurse reporting involves outgoing nurses handing over charge of the patient to the incoming nurse. Here, it is vital to effectively convey crucial details regarding the patient care plan and current health status. BSR performance facilitates participation by patients and their families in care. It also facilitates engagement in information sharing, which guarantees identification and alignment of the objectives of the patient, the healthcare team, and the patient's family. BSR enhances patient satisfaction, lowers patient fall rates, reinforces the patient–nurse relationship, reduces hospitalization duration, reinforces collaboration, and improves nursing staff prioritization and accountability at shift commencement.

Explanation of Causes and Proposed Solution

In the hospital under study, senior-level medical consultants who delivered bedside handovers conversed quietly and only with their peers — other senior practitioners. Highly sensitive information was conveyed using curtains to divide cubicles. Handovers were typically protracted, hurried, and unsystematic, within a noisy environment. Clinicians jostled for position while briskly walking between patients in order to hear what their peers were saying. Senior physicians could interact more easily and move closer to patients, but junior practitioners felt afraid and uncomfortable approaching the bedside or voicing their views, remaining instead on the fringes of cubicles. The latter also reported being overwhelmed by their workplace atmosphere, characterized by regular staff interruptions, disorder, and time pressure. They therefore preferred a submissive role during the clinical handover process. Furthermore, their suboptimal positioning during handover increased confusion, owing to the inability to accurately communicate crucial information (Mardis et al., 2016). Consequently, key findings were not verified at the time of handover. Although the BSR approach is valued by patients and practitioners alike (Mardis et al., 2016), it gives rise to challenges of noise, confidentiality concerns, and interruptions (Mardis et al., 2016).

Power-related problems can affect junior physicians attempting to assert themselves. Because they were situated far from the handover-delivering consultant, the hospital's junior providers could not hear clearly, hesitated to speak their mind, and worried that the process would be impeded if they posed questions. A nationwide handover practice survey found that clinical handover was typically performed only by senior providers, and not junior physicians, in 96 percent of healthcare institutions (McMurray et al., 2015). Clinical handover appears to be greatly dominated by clinical consultants, which may undermine junior physicians' confidence and discourage them from voicing their views. It also potentially contributes to the absence of opportunities for active participation and reinforces the notion that communication during clinical handover lies strictly within the domain of medical consultants.

Medical specialists represent another stakeholder group experiencing communication issues during handover. Their role involves managing distinct clinical care elements, and they can be subject to cognitive bias, in which unique educational and experiential patterns deeply impact an individual's processing lens (Ofori-Atta, Binienda, & Chalupka, 2015). A medical specialist's determination to adhere to particular care guidelines might bring about communication disruptions. Additionally, patients being situated in different wards is a second possible communication issue for medical specialists, as they must move from one ward to the next, potentially resulting in disorderly, fragmented handover.

At present, no preset policy exists governing how the hospital is to carry out shift-change reporting. Observations revealed that BSR was not consistently performed for various reasons. A microsystem evaluation was carried out to identify the need to improve the shift-change reporting process. Numerous reporting processes were observed, facilitating the determination of key problem areas. Frequent interruptions during handoff included call lights, interruptions by patient caregivers, or interruptions by the patient. Information conveyed at the time of reporting was typically inconsistent, and nursing staff were at times engaged in other tasks, such as patient examination, during crucial information interchange.

The HCAHPS (Hospital Consumer Assessment of Healthcare Providers and Systems) is a tool for measuring patient satisfaction based on their experience with a given healthcare system. Among the questions posed is how effectively nursing personnel communicated with patients or ensured they were well-informed. The hospital's most recent patient satisfaction scores linked to nurse communication stand at 65 percent — a decline from the required benchmark. Evidence indicates that BSR performance aids patients in being better informed and participating in their care process, thereby improving patient satisfaction levels (Salani, 2015).

A Strengths, Weaknesses, Opportunities, and Threats (SWOT) analysis was carried out to determine opportunities and obstacles to improvement. Identified strengths included nursing care providers' interest in novel practices and practice change, a history of PDSA (Plan-Do-Study-Act) cycles within the microsystem, team commitment to delivering superior quality healthcare, and previous implementation of BSR alongside an existing SBAR (Situation, Background, Assessment, Recommendations) instrument for shift-report navigation.

Several shortcomings were identified in the existing process. Employees are uncertain about what information to convey during reporting and how to convey it, which makes them feel BSR is time-consuming. Charge nurses fail to make the task accommodating; often, a single nurse gives or takes reports from two or three nurses, prolonging the process and frustrating staff. Additionally, the hectic environment — with hospitalizations and discharges occurring nearly simultaneously — commonly impedes nurses attempting to perform BSRs.

Opportunities with the potential to positively impact BSR include patient input in practice delivery and the support of the director of education and quality improvement. Possible threats to improving BSR adherence include fresh hospitalizations at the time of shift change, patients being asleep and disliking having their sleep disturbed, nursing staff uncertainty about how to handle confidentiality, the presence of patient family members at the bedside, and insufficient unit funds for organizing personnel training and instructional sessions.

BSR implementation represents a quality improvement undertaking. Key advantages include better communication among nursing staff and other providers regarding patient health status, progress, and plan of care; patients being better informed of their care process and care providers; opportunities for patient participation in decisions regarding their care; and improved safety and patient satisfaction. A Cause and Effect assessment was performed to examine the likely reasons underlying non-adherence to bedside reporting.

This BSR undertaking encompasses employee training and education. The 60-minute training session will cover role-playing, video, and instruction, supplemented by printed materials such as a guide covering main bedside reporting elements for individual nurses. Fifty-four registered nurses are employed in the orthopedic division, with hourly salaries ranging between $40 and $56 (average approximately $48). Personnel training expenses are anticipated to be approximately $2,592. Print material expense is estimated at $15. The training sessions will be co-led by a nurse earning $52 per hour; her services over five days will cost $260. Overall project cost is predicted to be $2,867.

Research reveals that BSR lowers rates of adverse events such as pressure ulcers and patient falls. Average fall injury expenses stand at $35,000 (Eggins & Slade, 2015; Mardis et al., 2016). If BSR were to avert even a single fall, the hospital could save approximately $32,653. Similarly, individual patient healthcare expenses for pressure ulcers range from $20,900 to $151,700 per ulcer (Tan, 2015; Ford & Heyman, 2017), with individual pressure ulcers adding roughly $43,180 to hospitalization expenses.

The BSR process is more time-effective and cost-effective than recorded reporting or station-based reporting. Outgoing nurses can end their shifts in a timely manner, preventing unintentional overtime and enabling incoming nurses to commence work promptly (Drach-Zahavy & Hadid, 2015). Individual shifts have three to four nursing staff, with average overtime standing at half an hour and costing $192 per shift. Achieving 100 percent adherence to BSR may therefore help save $5,376 in monthly nursing overtime pay.